Fall 2016

Funny that it seems my best time for reflection appears to be while high above the clouds and Mother Earth that I love so much. Perhaps it relates to the fact that these are the times of transition for me, often traveling between my two very distinct, but also in many ways quite similar, lives. In the Philadelphia area, where I have now lived for close to the majority of my life, are my family and friends, those that I have grown to know over so many years and that not only include those related by blood, but also my colleagues, my patients and, most importantly, the residents who I work with and who bring me great joy every day to see their amazing enthusiasm, expertise and compassion. They are some of the many lights of my life. In Tanzania, where I have now spent a year of my life with my combined fourteen trips over the last eight years, I have found new family and friends, not only among those who I have worked with so closely and at FAME, but also the many incredible souls who have adopted me as their family and have given so much of themselves along the way. I am forever grateful to have had the opportunities I’ve had in my life and for those many thoughtful and loving individuals who have made it possible for me to have had them. They are too numerous to name here, of course, as there have been so many. You know who you are, though, and you should feel the love and gratitude I have for you not only on this day of thanks, but on every day of the year, for without you I wouldn’t be the person I am today.

Daniel tackling a 14’er

Anna and Laila

I am not traveling to Africa today, of course, having just returned from my fall trip three weeks ago, but rather to Colorado, to visit my son, Daniel, who is living and going to school in Boulder. His journey has truly been an inspiration and for those of you who know him, I need say no more. For those of you who don’t, I could only hope for each of you that you have someone similar in your life. My other inspiration, Anna, who is currently living and working in Los Angeles, not far from where I originally grew up, has found her home and her calling for now on the opposite coast and will have to wait for my visit in the near future as we are now spread across the country. Anna’s life has taken her to such far away places as Turkmenistan, Egypt, Jordan, and Turkey on her own, not to mention that she was the original inspiration for me to have gone to Africa, accompanying her on safari through our mutual love of animals. I have been blessed with two absolutely amazing children and am so thankful on every day of the year to know them for the wonderful individuals that they are.

The Raynes House nearing completion

On this day of thanks, I am also grateful to those who have continued to support me in the work we are doing in Northern Tanzania and at FAME. We have been allowed to enter a world so often very different from ours, where so much of what we take for granted is just not possible, yet with your help we have brought some light to the world of those who are without. As you know from reading my blog, we are now nearing completion of our new volunteer home at FAME, the Raynes House, that will allow us to continue our work into the future. Before it is ready for occupancy, though, it will need furnishings such as beds, sheets, towels, dishes and all the essentials for us to live there while we provide our neurology clinics at FAME and our mobile clinics to the surrounding villages. I would ask for your continued support by visiting our campaign website and considering a contribution to this effort:

For those of you that have already donated, I thank you from the bottom of my heart. And to everyone, I wish you a very wonderful and happy Thanksgiving as we all have so much to be thankful for in our lives.

I had stayed the extra day to spend time with the Temba children as well as Leonard and Pendo, but it was odd not having Kelley and Laurita with me. We had spent the last month together, every moment of every day, and it was truly a pleasure to have been able to introduce them not only to the world of global health here in East Africa, but also to the Tanzania culture that I have so come to love over the last seven years. The diversity, the resilience, their love of life and their respect for each other is something to be treasured and learned from. In a country whose independence came a mere 55 years ago with 121 different tribes, some still at war until only 30 years ago and one of the poorest countries in the world until only recently, they have achieved great things in such a short time. There were only 11 Tanzanian college graduates in 1961, when they gained their independence and they now have many universities and colleges. As with any highly populated African country there is still much more to do, especially in the health care arena. That will take time, but hopefully we are making a small impact in sharing our expertise with them while learning so much more from them.

Lenox has become an excellent football player – following in his father’s footsteps

And Lee is coming along as well

Lenox had asked if I had any movies that I could share with him last evening and when I went to look for my external hard drive that I carry with me (I bring no computer, only an iPad on which to blog) I couldn’t find it. The last I knew of it was when Kelley and Laurita were using it to transfer Puerto Rican and Tanzanian music to and from a thumb drive for Sokoine in the back seat of the Land Cruiser as we traveled to Arusha on Friday. I searched all my bags and the Land Cruiser, but Leonard had taken it to get cleaned early Saturday and it wasn’t there. I reached Kelley by email and replying from Doha she told me that she was 99% sure she had put it in the pocket behind the driver’s seat when she was done with it. All of our photos from the trip were on it which would have been a huge loss. As a last ditch effort, Leonard called the owner of the car wash where he had left the vehicle that day to see if they had it. He was still at church, but would call us back when he got to work. Thankfully, he called later in the morning to tell us that it was there and we could come pick it up. Disaster averted!

Pre-game warm ups

Leonard doing his exercises is in the middle

Leonard used to be a very good football player (soccer, of course) and still plays every Sunday morning with the Arusha All-Star Alumni team. He hadn’t planned to play today since I was still there, but since my flight didn’t leave until 5:30 pm, I thought we had time to go for a bit. I had gone several years ago and had a great visit taking photos of all the players and sending them to Leonard. Besides, both Lenox and Lee were coming so it was a way to spend time with them as well. These players were, in their prime, the best of Northern Tanzania and many of them were probably of Olympic quality. They now play on a community field that is mostly dirt with enough vegetation only to keep it from blowing away. It is rather high on the slopes of Mt. Meru, in the village of Ilburo, and many children come to watch these games which are often against neighboring clubs.

The Arusha All-Star Alums

Leonard passing the ball

A down moment

Dribbling the ball

Today, they played amongst themselves, but you wouldn’t have known it based on how hard and, at times, rough they played each other at position. Before playing, they go through a long warm up, running up and down the field doing variously maneuvers to loosen up and prevent injury. I enjoyed taking photos of the players and waited for half-time as we would have to leave early to get me back home and then to the airport. We also had to pick up my hard drive. The game went on as they had decided to play through half time so when I told Leonard the time we prepared to leave. They stopped the game, though, and everyone came to sideline as Leonard wanted me to say something to them since I was again the only mzungu there so presence hadn’t gone unnoticed. The club president introduced me and said a few words after which I thanked them for allowing me to be there and share in their love of football. I donated some money to the club as did Leonard for them to continue and they thanked me profusely. In March on my return, I hope to bring them some supplies that are nearly unobtainable in Tanzania, like good football socks and shin guards. As in everywhere in Tanzania, they make do with what they have which is often not very much.

We drove home and loaded my luggage as I was mostly packed. We had a quick lunch of meat with vegetables and spaghetti and then left for the drive to the airport. Saying goodbye to the boys and Gabriella is always tough as they will be six months older next time I see them. Gabby is growing like a beanpole and will be talking by then. On our way to the airport we made a stop in USA river to see Leonard’s friend who had had the stroke several months ago. They had obtained his CT scan from KCMC for me to review and it demonstrated a very large hypertensive hemorrhage in the left basal ganglia with intraventricular spread. He was still hemiplegic and mute with good understanding of speech and it is questionable how much of that will return over time. We stayed for only a short time as it was getting late and I needed to check in at the airport. Not counting my driving others to the airport, this is my 14th time flying out of here and the small upgrades are actually noticeable. They now have a small cafe in the waiting area which is a huge addition to what was previously an almost unbearably hot and desolate place with barely a bathroom to speak of. A small bit of progress is everywhere here, some good, and some, like the traffic in Arusha, not so good. Still, it is always tough for me to leave, as I believe it is for everyone who visits this often simple and sometimes complex country that has so very much to offer in so many ways. The people are beautiful and always giving while the land is amazing and often harsh. I look forward to returning in six months time and will be counting down the days.

Having now experienced the Maasai Market once and having perhaps a better sense of strategy, it was Laurita’s and Kelley’s intention to subject themselves once again to this somewhat nerve wracking experience and to so willingly. One might consider this an indication for a psychiatry consultation or to just skip that step and place them on heavy antipsychotic medications, but I did neither and decided to let them run with it. We all slept the night under mosquito netting as is usual for Tanzania, but even more so in Arusha where the mosquitos are bigger, faster and more persistent than in Karatu. They are unrelenting thugs. Though the girls slept well under their netting with no insect incursions, I was not so lucky as I had apparently not tucked my netting in quite so carefully. Trying to describe a night shared with these little beasts trapped in your netting would best be accomplished by referring you to the latest horror flick about being locked in a house with your worst nightmare. And better yet, there is no escape as their little friends are just waiting for you to run outside so they might pounce. Once you’re shield has been penetrated, you can look forward to, at best, an interrupted night of intermittent sleep in between their attacks and there is no clearing your net once the night has begun. That was my Friday night.

The children arose rather early despite having arrived from Nairobi at around 1 am. Pendo later told us that they were stuck in a three hour traffic jam in Nairobi, which has to be one of the very worst cities for traffic I have ever seen. We stayed one night there on our return in 2009, and it had taken us hours to travel a several mile stretch of the main road from the airport with at least four lanes of traffic in each direction. Definitely not for the faint hearted. We had coffee and wonderful African chai with all of its spices before sitting down to a breakfast of pancakes, eggs, toast and fresh fruit. By this time it was well after 10:30 am and we very much needed to get to the Maasai Market for Kelly and Laurita to finish their shopping.

Setting up the buffet

The seating for the bride and groom

Arusha has become a very congested town for driving with very few traffic signals for a city of well over one million people. The normal route to the market was quite congested and it took us well over twice as long to get there as it should. We finally arrived and thankfully there were far more shoppers than the prior evening so you didn’t feel as much as a target as before. Even with that, though, the vendors from last night remembered and us and their common line was “remember, Baba, you told me last night that you’d look in my shop when you came back today.” Whether they were telling the truth or not, really couldn’t be totally sure so you just believed them for better or worse. We were pushing our luck with time to get to the airport, but I waited patiently for the two of them to finally wrap up their shopping and we drove back to the Tembas to finish their packing and head off to the airport for their flight home. I did take the back way to home this time which was a breeze and made me ask myself why I don’t use the route every time which must clearly indicate that I’m becoming more a local driving here in Arusha these days.

Guest seating under the tent

Before I knew it, the girls were packed and they had their bags in the car ready to go. The drive to Kilimanjaro International Airport, or KIA as we refer to it here, is along the Nairobi road that is on the north of town and heads to Moshi at the foot of Mt. Kilimanjaro. The airport is between the two cities (Arusha and Moshi) and sits in a big dusty plain that is just north of the Blue Hills, which is where all the Tanzanite is mined and the only place it exits in the world. Unfortunately, the road is currently being widened and the construction goes on for several kilometers. To say that the roads are poorly marked in Tanzania would be an understatement, and when you put two, two-lane partially finished tarmacs parallel for any distance, it makes for an interesting journey here. Drivers try to take whichever route might be the shortest and quickest, so just when you thought you might have two lanes traveling in the same direction on either side of a median (otherwise known as a divided highway in our country), you probably guessed wrong and you find yourself with oncoming cars or trucks in the lane you thought might be yours. In the daylight it requires quick reflexes and a bit of imagination. In the dark it would be otherwise very treacherous or just as easily referred to as suicidal. We were driving a much smaller car to the airport and, for once, I had wished we were in the big Land Cruiser as it gathers a bit more authority when one is trying to prove his point.

The bride and groom arriving

An amazingly handsome couple!!

We survived the construction zone intact and were finally on the open road which is still just the original two-lane highway that brings on it own set of nuances when trying to make a flight and being a couple of minutes later than you had planned. The trucks here come in every state of disrepair and when time is not of concern and fuel is the limiting factor, they drive like snails going uphill making it a necessity to pass them or else leave a day early to make it anywhere. That wouldn’t be a huge problem, other than the fact that there are small towns every few kilometers that have speed bumps and 50 kph speed zones. The Tanzanian police who used to only have their random traffic stops to shake you down if you didn’t have all your stickers and safety equipment in your car, now also have the speed traps to generate extra revenue that are set in these speed zones. Leave it to say that travel here is always an adventure whether you’re on a game drive in one of the parks, or just just trying to get from point A to point B. I guess that’s one of the things I like about this place which must sound very crazy to all those who are not familiar with how much I love to drive (which is very, very much).

Greeting the guests

What smiles!

I dropped them off at the airport and we said our goodbyes with extra hugs even though we’d see each other in several days at work. Now I had to get to Sokoine’s wedding and luckily I was just trying to make the reception and not the church ceremony. I fought the never ending traffic through the construction zone and arrived a bit late, but luckily found that they were still taking photos at another location. The reception was at his in-laws house which was all set up with tents and chairs and the caterers were getting everything prepared. I sat with some relatives who were waiting for them to return as well and we shared some bottles of water sitting in the shade of the tents in the hot midday sun. It was a splendid setting. Finally, a Land Cruiser arrived with the typical decorations that are seen with wedding parties here and eventually Sokoine and Upendo got out to the cheers of all the family and neighbors who had accumulated by this time.

Sitting during the ceremony

The champagne toast

I won’t go into the description of the entire ceremony, but leave it say that it was one of the most beautiful wedding receptions that I have ever been to as everyone participates and says things along the way. It was all in Swahili and at several points, the master of ceremony spoke English for my benefit as I was the only mzungu (stranger or white person) there out of the 75 or so guests. They had a champagne toast (the only alcohol at the wedding as the Maasai don’t typically drink) and a cake cutting ceremony quite similar to ours, but after they gave each other a piece of cake on a toothpick they preceded to call out several other family members to give cake too as well. Imagine my surprise when I was called up to receive my piece of cake on a toothpick from both Sokoine and Upendo. You may recall that this is what I had to do for the entire kitchen and service staff for my 60th birthday party in March. I was so honored over have been not only invited to the wedding, but also included as a family member. Sokoine kept looking over to me to make sure I was being taken care of not neglected, but it was far from that as everyone made totally sure that I was included whether it meant getting a soft drink, in the dinner line (you would have loved it Laurita!) or just knew what was going on.

Cutting the cake

It was supposed to have been a small affair, but here in Tanzania, a wedding is a community event so not only family, but also neighbors are welcome to attend and have something to eat. I hadn’t counted on being there the entire night which I could have easily done and would have loved to, but I needed to get back to the Temba’s at some point as I had their car and also wanted to spend some time with them. The dinner was to be at 6 pm, but it was well after 7 when we all got in line for the buffet. It was white rice, pilau, banana stew, beef stew, salad, fresh fruit and several other dishes I didn’t recognize, but just ate anyway. Tanzanians pile their food quite high on their plates, but I did take smaller portions even though I was starving as we hadn’t eaten lunch before heading to the airport. Everything was delicious and when I went to sit at my chair, Upendo’s father grabbed me and had me sit with them at their table. I couldn’t believe how much everyone was attending to me. Earlier the master of ceremony had asked me if I would mind giving a toast at some point, but they hadn’t yet called me up to do so and it was getting quite late. Sokoine asked me on several occasions if I needed to leave as he knew of all my obligations so at 7:30 pm (I had told my Pendo that I’d be home around 4 pm) I told him I had probably better get on the road home.

Feeding each other a piece of cake on a toothpick

And now for family – which included me! This is Sokoine’s brother, John.

If I had had the opportunity to give the toast (I had already thought in my mind what I was going to say) I would have told everyone how much Sokoine meant to me in the time we’ve worked together over the last several years as he is perhaps the most capable and trustworthy friend I have here other than Leonard and Pendo. What we accomplish during our time at FAME would not be possible without him and the preparation he does to make things happen here. He is truly an amazing individual who has not wasted an opportunity to better himself with his education, his work and his family, and I very much respect him for that. I’m pretty sure he knows how I feel and I also know that he is meant for far bigger things than working with me and at some point he will have to move on. I will be very sad on that day, but sincerely very, very happy for him and his family of which I am now a part.

It is never easy to leave FAME, both emotionally and logistically. I should have learned this long ago. The times we’ve planned a safari on the way to Arusha seem to work the best, as we leave before sunrise and there are no goodbyes or late packing to deal with. As we had done our major safari last weekend and I had promised the girls that I’d take them to the Maasai market in Arusha to buy gifts, we decided instead to leave mid morning and would pick up Sokoine in town around 10am. Best laid plans as I’ve said before.

Kelley and Laurita’s final lecture and our final morning report

Kelley and Laurita still had one more talk to give at 7:30am (their third this week) and so we all headed up to the conference room at the early hour to talk about headache. Of course the talk went great as both of them are incredible educators and once again, Dr. Lisso held his tongue at the witching hour of 8am and let them continue. As it was our last morning report, we each said a few words and then headed off to get things done. We still had three patients in the ward – our young boy with meningoencephalitis, our girl with Sydenham’s chorea and a the gentlemen with Wernicke’s encephalopathy that I think I had mentioned before. If I didn’t though, it was a great pickup on Laurita’s part and he was now receiving his thiamine. We had to write final plans on them for our departure so the staff would know what to do going forward with each of them. Amazingly, all of the charting had been completed by Kelley and Laurita so there was nothing left to do there. We headed back to the house to get packed as neither of us had done any of that yet. Of course, we had to have a snack first of the left over rice from last nights dinner that Kelley fried for us with some egg while we watched segments of Samantha Bee that we all love with her commentaries on the current election. Thankfully, we are all exceedingly of the same political persuasion which makes things a little easier.

In front of our home, sweet, home

I think they enjoyed their stay

Packing for me does take a bit of logistics as I have things that I leave there each time such as our ophthalmoscope kits and I have to remove all the batteries from them as I found this out the hard way on one occasion and spent a day scraping out battery acid from their holders after the batteries corroded inside. I have a large duffel filled with my clothes that I leave, an extra pair of shoes, crocs, rain boots and all of my medical tools and references. Soon, after the new house is built, I’ll have a locked closet to leave everything in that will make things much easier for me. Once packed and the Land Cruiser loaded, I wanted all of us to walk over to the Raynes House for a quick inspection of where things were. The house is really taking shape and now has all the window frames in. The roof is complete and they are finishing the outside surface of the walls with concrete about the exposed brick. It really looks amazing. I think we’re in good shape for a finish prior to our return in March.

No, she’s not in jail. The window frames are now in the Raynes House

Finishing the outside of the Raynes House

Eyeing the new home for the Penn contingent

Now it was time to drive down and say our goodbyes. Since I’m always returning in six months, it’s never really that difficult for me to do this. Kelley and Laurita, on the other hand, had become quite attached to everyone here and I could see it was difficult for them. We made our way through the outpatient clinic, the administration building, the lab and the ward. Selina was somehow nowhere to be found when they initially went through, but I bumped into her on her way back to the clinic and sent the girls to find her. When I found the two of them they were pretty choked up as Selina had cried saying goodbye and that was about all they could take. We realized that we almost forgot to say our goodbyes to Mama Susan so we went to her office and found her. It was obvious I think at how emotional the two of them were. Susan was her amazing self as usual and we headed for the Land Cruiser to drive downtown. I did mention that we had told Sokoine to meet us at 10am, but by now it was 11:30 am and we still had more errands to do in town. First was to pick up our final gifts from the tailors shop that required me to get some shillings and both Kelley and Laurita to visit the ATM both for this and their plans at the Maasai Market.

Our visit with Daniel

Saying goodbye to Daniel Tewa

Then it was a visit to Daniel Tewa’s home to say goodbye. That is never easy and, of course, Daniel had African coffee ready for us so we all sat down in his living room (the center room of his Bantu-style house) to enjoy the noontime coffee boiled with milk. Both Laurita and Kelley had wanted to look at some things that Daniel had for sale in his house as he has safari groups often come by to see him original Iraqw home and to give a presentation of Iraqw culture. We all enjoyed the coffee which can’t be chugged given how hot their thermoses keep liquids here, so we just relaxed and enjoyed the friendship while the girls did some shopping . Sokoine had never met Daniel before, so it was fun for the two of them to banter back and forth since the Maasai and Iraqw were enemies for so many years mainly over the fact that the Maasai believe all cows belonged to them and taking them from the Iraqw was merely returning them to their rightful owners. We left Daniel’s to hit the road for Arusha, about 1-1/2 hour drive, all on tarmac.

The drive went quickly with a stop in Makyuni for fuel and before we knew it we were in the outskirts of Arusha. I had wanted to stop at the Arusha Coffee Lodge as the Shanga Shop is now there and it is a great place to shop for gifts. They employee people with physical disabilities who make things out of recycled glass and other materials. After this, we were off to drop Sokoine at his in-laws house where his wife had come yesterday from Karatu and where his son lives to go to school. They live in Mianzini, a small suburb of Arusha on the north side of town on the slopes of Mt. Mere. Most importantly, Sokoine had informed us on the ride into town that he was getting married tomorrow!! They had never really had a formal ceremony and the affair was going to be the following day and he asked me to come. He would have love for Laurita and Kelley to come also, but unfortunately they were flying out just after noontime and that wouldn’t work. As I had to drive them to the airport, I would be back just in time for the ceremony.

Sokoine, Upendo and Ibraham

As with any visit to a Tanzanian household, one can never escape some type of a meal (we were only able to leave Daniel’s with just coffee as I told him that we were running late getting out of town) as it would be considered rude to have a guest and not offer them something. They had prepared us Pilau, which is meat flavored with chunks of beef in it, and soft drinks. We were actually quite hungry as we hadn’t had lunch so it was very much appreciated. Sokoine’s wife, Upendo, is lovely, and his 3-year-old son, who looks just like him, is amazing. We left their house to head to the Maasai market, but before we could leave, I had to back an incredibly large stretch Land Cruiser out of their gate that opened onto a less than one car alleyway with shops directly across. After almost completely collapsing a row of shops as I couldn’t see the post behind my vehicle with the side mirrors and it wasn’t until Sokoine and Kelley got out to tell me that we were finally on our way.

The Maasai Market in Arusha is an experience to say the least. And arriving in evening when there are far fewer mzungu around can be dangerous and give one the feeling of being fresh meat. There are at least 100 stalls that are under cover, kind of, and all carry mostly the very same thing – beadwork, paintings, carvings, knick knacks, wall hangings and ever other imaginable tribal piece of art or craftwork. All the vendors stand immediately outside of their stall and try every which way to get you to enter their little shop to possibly buy something however small. It is mind boggling and mind numbing at the very same time. I’m not sure that Kelley and Laurita were quite certain exactly what they were walking into, but they quickly discovered the real ambience of the place. You end up loving it, though it does take some time getting used to it. We bought a few things that evening with the intention of going back the following morning as neither of them had completed all of their shopping and we were all pretty pooped from the day. We left the market when it was pretty much dark and getting a bit scary to be walking around.

We drove home to Leonard and Pendo’s house where we’d be spending the night. Leonard was our safari guide who introduced me to FAME and who I owe everything I now have in Tanzania to. I have had residents stay with the Tembas for virtually every trip I have brought them and they remain as gracious as ever, making sure everyone has a bed for the night and serving whatever meals are needed. They are truly amazing. Pendo had driven to Nairobi for the day to pick up the their two boys, Lenox (11) and Lee (7), who are going to school in Nairobi and were getting out for November and December. Leonard was working in town when we arrived to their home, but we were able to enjoy the company of Gabriella, their youngest, and Pendo’s sister who cares for her when they’re gone. Leonard arrive a little bit later and we all had dinner together as Pendo had been delayed in leaving Nairobi and wouldn’t be getting home until very late with the boys. We all went to bed before 11pm and were quite exhausted from the day between the emotions of leaving FAME, the drive, and shopping.

Both Kelley and Laurita had agreed to do two more lectures for the medical staff. The first was to finish the talk on evaluating an unresponsive patient that had been started on Tuesday, but they had run out of time. Dr. Msuya also wanted them to do the talk on headache that they had originally planned for last Tuesday, but had been preempted by the unresponsive patient talk which has been in response to the patient last week who had not survived his code. Since the nurses were using the conference room for their regular morning education lecture, we decided to use the education room in the admin building that doesn’t have the big screen TV like the conference room, but does have a small LCD projector for PowerPoint presentations that can be shown on the whiteboard that works quite well. Laurita finished the lecture in about 30 minutes which meant that we were on schedule for morning report.

Laurita finishing her talk on evaluating the comatose patient

We hadn’t planned on seeing any patients today, but as we’ve come to expect, there is almost no way that we can be here and not have patients to see as it seems that patients show up looking for us no matter what. We were working in the volunteer office, me composing my blogs and Kelley and Laurita working on data entry, when Sokoine came looking for me to tell that there were a few patients to be seen. As usual, it is often those who most need to be seen that are the ones who straggle in at the end of our visit here. It would be unthinkable for us not to see them given the difficulty to find any specialty care here and the fact that we won’t be back until March of next year.

Laurita getting the history on our young boy with weakness

I watched them wheel the first patient in for Laurita and it was a young boy in a wheelchair. I decided to follow him in since I had some suspicion about his diagnosis and wanted to be there since it is not something seen by our residents often and certainly not as a new diagnosis as I didn’t recognize him as having seen us before. He was an 8-year-old Maasai boy who had been brought in by his uncle who he was living with as his mother could no longer care for him. His main complaint was that he was having pain in his legs and was unable to walk any longer. His symptoms had been present for several, but he hadn’t walked in four months. Weakness was only his secondary complaint, but I knew from being here so long that this was a bit misleading.

Our young patient with Duchenne’s muscular dystrophy

One of the tough parts about taking a history here is that patients often create complaints to explain their deficits which requires a bit of practice to tease out the real problem. A young boy who can no longer walk doesn’t necessarily complain of weakness, but rather will explain that it “hurts” for him to walk, meaning merely that he can’t do it. When Laurita began to ask questions about his pain, I subtly told her not to worry about it and to ask more questions about why he couldn’t walk. What came out was that he actually had weakness in the legs and arms that had been getting progressively worse over the last several years to the point that he couldn’t walk. His complaint of leg pain was what we call a “red herring” and wasn’t his primary problem. When still walking earlier in the year, he had been seen at FAME and diagnosed with a polyarthralgia for which he was given ibuprofen. His history was further bolstered when the uncle said that he had an older brother with the same problem. His examination was quite classic with proximal greater than distal weakness in his upper and lower extremities, pseudohypertropy of his calves and a very classic Gower sign when he tried to get up from sitting on the floor. Laurita originally wanted to spare him from having to do this, but I felt it was important enough for her to see this finding in person as that is the real way we remember things.

We had a discussion with the uncle, initially through Selina and then through Sokoine, who speaks Maa since he’s Maasai, as we wanted to make certain that the uncle fully understood the prognosis for his nephew. It is often very hard to tell situations as the Maasai like many tribes here are very stoic and often don’t volunteer their emotions quite the same as we do in the west. We did institute steroid therapy as that is one thing that has been shown to help maintain ambulation, but it is not in any way disease altering and certainly does not extend life expectancy. Since the boy had stopped walking in the recent past, I thought it was worth a shot to see if perhaps he could regain some function, though it would only be on a limited basis. He will need to watched closely on the steroids to make sure he doesn’t have any side effects and there is a small increase in his risk of infection which is always a concern here in rural Tanzania. We also asked that he come back once Dr. Reed is here next month as he will need to have a cardiac evaluation with an echocardiogram as these children have cardiac complications as part of their muscle disease. As unfortunate as this diagnosis is, it is always rewarding to be able to diagnose a condition with certainty so that a family will hopefully not have to go on searching which is quite often the case here as families typically don’t get answers and then travel from facility to facility looking for them. At least we can give them the answers they seek and spare them from the unknown, or at least that is our intention and we do the best we can at it.

Kelley evaluating the patient with a spinal cord infarct

Kelley’s first patient of the day was a gentleman in his 40s who had been seen by Dr. Frank in the past and was from Arusha. Frank had shown me a CT scan on Wednesday and had asked what I thought about the story so I told him if there was any way possible for the patient to come on our last day it would certainly be helpful to examine him which was the interesting of the case. The patient had been previously well until earlier this year when he was walking with his wife and suddenly collapsed to the ground without any loss of consciousness, but was quadriplegic. I had told Frank that from the sounds of it he had a vascular event in the spinal cord and if his arms were involved that it localized to the cervical spine, but the CT scan had been done of the thoracic cord only. He did indeed have an asymmetric quadraparesis that had improved somewhat from the onset of the event and a sensory exam that demonstrated a level at the low cervical region. He also had crossed motor and sensory findings confirming the location was in the spinal cord. There was very little else that could have done this and even though we suspected a low cervical cord process, we found very little reason to obtain a CT scan as it would not change his management at this time. We did offer him some medications for neuropathic pain and for his spasticity which might help make him more comfortable overall. He may continue to regain some function, but unfortunately he will never be independent or be able to lead a normal life and at a very young age.

Kelley evaluating a young seizure patient

Laurita and Kelley checking out the little premie

Mama and baby

So we had actually planned not to see patients today, but ended up working until around 2pm or so and still needed to hand out blankets to mothers with newborns. A patient of mine at home, Mildred Staten, and a group of her friends crochet (I’m hope I’m correct on the process) blankets for newborn babies that they distribute in hospitals back home in Philadelphia and a year or so ago she had asked whether I thought they would like them at FAME. We brought them last October and it was a huge hit on the maternity ward, so we had brought them again and hadn’t yet had a chance to hand them out as we had been so busy seeing patients every day. We went to Ward 2, the maternity ward, with Sokoine as our interpreter and photographer, and each had a small stack of baby blankets for the mothers to choose from. It is so enjoyable to see the mother’s faces light up as we offer them a blanket and each mother eyes the blankets to find the one she likes the best for her baby. There are several premises in the ward right now, one of whom is in an incubator and ways a mere 0.76 Kg, or 1.67 lbs. The baby is just so very tiny, but has been holding their own since we’ve been here and seems to be thriving despite everything. It is a miracle to see these babies fight so hard to stay alive and it is this resilience that exists among all those we meet here. It is clearly something born in each and every Tanzanian and part of why we are so privileged to work and live with them. The blankets from Mildred and her group of women were very much appreciated by every mother we presented them to and I am sure by each little newborn, big or small.

A young mother choosing her baby’s blanket

Another little premie, though a bit larger

It has been a tradition it seems for Frank and Susan to have a get together for our team the last night or two of our departure. This trip was no exception and we were all meeting this evening at their lovely home that sits just above the volunteer houses as if to keep an eye on everyone though from an appropriate distance. Alex, our new volunteer coordinator as of two months ago with Pauline’s departure, had taken it upon himself to personally prepare the menu for tonight. The party of typically catered with pizza or similar, but tonight we were having a feast of Mexican food with homemade tortillas, corn salad, homemade salsa fresca, lettuce and rice. Most of the vegetables were from FAME’s garden. Oh, and I forgot to mention that Alex was unable to find good group beef in Karatu so went instead with some unreal sliced filet that was out of this world. Frank had forgotten that he had a talk to give on animal borne pathogens in Africa to some visiting doctors that he does annually so was running a bit late. We all gathered at their house just after sunset – there were about ten of us without Frank – and just sat and relaxed before dinner with popcorn, beers, soft drinks and wine while Alex and Laurita worked in the kitchen. Kelley was told there were too many cooks in the kitchen, but she and I were fairly certain that it was excuse for Laurita to sample the cuisine as it was well after her dinner time. She swears she didn’t, but neither of us really believed her. As we sat on the veranda with their three dogs – Molly, Nickie, and Oscar (their new mostly Rhodesian ridgeback puppy) – and Charlie, FAME’s mascot (Popie, who is now very aged, no longer partakes in parties) roaming around getting lots of love from everyone. Elvis, their fairly rare Kenyan or Ethiopian cat (I can’t recall which and what the name of the breed is), also showed his face from time to time.

Mama and baby

A Maasai grandmother checking out their blanket

Frank arrived finally after his talk just in time for dinner and couldn’t believe that were than just scraps left, so he was very excited to join in the food line as it really was amazing. Somehow, though, Frank never left the food line as I didn’t see him on the veranda again and noticed that he stayed in the kitchen munching until it was after his usual bedtime of 8pm. I’ve been at these enough to know that Frank usually just slips off to his bedroom without saying goodnight and those that aren’t familiar with this ritual will look around and wonder where he went. Given his work schedule, he needn’t make any excuses and I know that he’d agree with that.

Posting a note from Mildred in the maternity ward

The party continued for a while longer as we just relaxed and told lots of great stories of FAME, past and present, of how it’s changed over the years, and where it’s going. Stories of travel and aspirations which is always amazing when you consider the diversity of the group sitting around the table. A Swiss pediatrician who has worked in Africa for a number of years, a cardiology physician assistant who has been here for long stints in the past and worked with me before, a Swiss emergency room nurse here for her first time, a retired professor of laboratory sciences who built the lab here and spends nines of the year here, two neurology residents working in Africa for the first time and trying to decide where their careers will take them, our volunteer coordinator who just finished with several years working at a primate rescue in Ecuador, and then me and Susan. Susan has committed her life to FAME along with Frank and they have successfully built a health care facility out of nothing that now rivals any institution in Northern Tanzania and employs well over 100 Tanzanians. They have truly changed the lives of countless patients as well as the residents of Karatu whose families benefit from their employment by FAME. And then me.

Global health had never been on my radar screen until very late in my career, but it was the education aspect that had always been the most important part of my work and that led me to FAME on that fateful trip in 2009. Still, it was not a given that I would return and there was something that drove me to do so and it is so hard to explain. We all look for purpose in our lives and providing the care for my patients and teaching residents had obviously been totally fulfilling for me through many years. There must have been some unknown void, though, that lead me here, to return again and again, and to bring those individuals who I knew would equally appreciate the significance of what we are achieving here. And in doing so, I hoped to impart in them the same enthusiasm I have not only in practicing neurology and teaching, but also to see the World as a smaller place without borders where we all speak the same language of love and deep down, we all have the very same values. The residents that have accompanied me here have all found this very same message on their own, and even more so, have managed to teach me more than I could have ever hoped for. This is my legacy.

I have been here now for nearly a month and between us, this is our 16th day of neurology clinic and the patients continue to come. We had planned for today to be a day to catch up at the end and complete our data entry for the patients that we’ve seen and a chance to take the “neuro team” all out to dinner for an evening on the town. It’s been an incredible visit so far and both Kelley and Laurita have easily managed to become a part of the family here such that it will be very hard for them to leave. The work here is like that. It’s so easy to get caught up in your own life at home and your own work schedule, but here that doesn’t happen. Everyone is working together for the same goal and the pace is much different. There are none of the pressures that we always seem to be under and which occupy so much of our energy to deal with. Here it is pure and simple. We wake up, we walk to work, we see a large number of patients, most of who have very little in the world, but have done what they could to get here to see us because they are concerned. We practice medicine as it has been practiced for centuries, listening to the patient and examining them, making an assessment and offering a treatment plan. Sometimes we have something to offer and other times we don’t, but we take our time explaining to them what we believe is going on. It is this time honored tradition that has brought each of us to medicine and has brought each of us here to Tanzania. This is what we have been seeking.

Our little patient with infantile spasms who’s doing well

Each day was truly “unadvertised” this week, but yet we have patients seeking our care that have often traveled far and cannot be sent home. And they are all patients in need of our services. Today was Kelley’s day for pediatric neurology and she was very happy to have me sit in on her cases as they were all complicated. First was a young child who had been seen by Dr. Jackie in March and diagnosed with infantile spasms and developmental delay. Infantile spasms are typically associated with a very poor prognosis and we had seen them two weeks ago and the child had been off of their antiepileptic medication for about a month and had had no return of the spasms. We wanted to leave the child off the medication if possible so asked them to return and that we would contact Jackie in the meantime, which we did and she suggested leaving the child off medication unless either the seizures returned or she regressed in functional status. Neither had occurred so we opted to leave her off the medication, but to return if she had more events or had any functional regression. The family was quite happy with those plans and we sent them on their way.

The cutest little patient we’ve seen yet who had febrile convulsions

The next patient she saw was an 18 month old boy who had been having a number of febrile convulsions, perhaps monthly, but with an episode of complex febrile convulsion in July as the event had included focality with the child shaking on one side only. We always worry with that type of seizure as there could be something structural intracranially, but the baby had been seizing for some time and his exam was entirely non-focal. He was very well advanced developmentally and was bright and interactive in every aspect. We told his parents that the seizures were febrile, but there was an increased risk of epilepsy due to the complex nature of the one seizure. Unfortunately, there really is no good data on the subject and the jury is still out. It is still felt, though, that daily treatment with a prophylactic medication may have to greater risks than benefits. We did not prescribe an antiepileptic medication for the child, but did decide to send an email home to Jackie to see what she would do in the situation. I believe we’re not far from starting medication, but we’d love to have her thoughts first and can easily bring the child back in if she feels otherwise. Meanwhile, he had to be one of the cutest babies we had seen while here and he definitely entertained us during the visit. I have a little frog with a light that I had found at CHOP and he loved playing with it, but was not very happy when he found out that I was not giving it to him to keep.

Kelley demonstrateing excellent use of both hands in the patient

I asked at the end of the visit if we could take him home with us

The very next patient for Kelley was another baby with a much different story. She was 14 months old and her mother’s pregnancy with her had been normal and she was normal at birth by report. But then, at 3 weeks of age, she began to have multiple seizures per day and her parents didn’t bring her to a hospital to be seen for at least a month. At that point, she was placed on phenobarbital which she remained on, but continued to have seizures, though perhaps a bit less frequently. She was having them perhaps several times a month, but then began having more seizures again most likely as was now underdosed on the phenobarbital because of her growth. The child was developmentally very abnormal doing very little on her own and was not crawling. Though she was initially sleeping when Kelley went to examine her, it was readily apparent that she was quite abnormal with nystagmus and a right gaze preference, failed to attend whatsoever once awake and couldn’t hold her head up. She was spastic throughout all of her extremities. It was pretty heartbreaking as I don’t think her parents really understood how grave the situation was at the beginning. I will have to admit that these are the children I chose not to see in practice ( I always said that I didn’t see floppy babies!) and so we also emailed Jackie about this child to her input. We of course adjusted her dose of phenobarbital which was the obvious thing to that even we were capable of as big people neurologists. I should mention to you here that on my first trip to FAME in 2010 and when arriving to clinic one morning with a long line of patients, half of them being children, I lamented to Frank that I’m not really a pediatric neurologist, at which point he quickly replied to me, quite seriously, “right now, you’re the closest thing that Tanzania has to a pediatric neurologist.” I learned my lesson then that we have to make do with what we have and do our very best for each and every patient.

Laurita evaluating a headache patient – Kichwa!

Laurita had a very interesting elderly patient whose problem was that she had episodes where she would begin singing and praying, but would still be responsive during the episode. This had been going on for many years and, of course, occurred during the visit when she began chanting and rocking in her chair. Laurita came out to get me so I could observe the episode which was clearly a conversion disorder and not a seizure or, as often they are considered here, demon possession. She was very responsive during the episode and could answer simple questions, but continued for some time with her singing. We later got the history that these episodes had started when she had killed a snake and some blood had gotten on her face during the event. When she went to wipe the blood from her face, some of it got into her mouth and this is what precipitated the behavior. We recommended using an antipsychotic medication to see if it could decrease the episodes, but what she really needed was psychotherapy which just isn’t available here in any shape or form. One might think that she could get some help from her church, but unfortunately it is often the pastors at the churches who propagate the demon possession explanation for them which only worsens the stigma to the patient and family.

Laurita evaluating her patient with episodes of singing and prayer

Sometime after lunch we were called to the ward to evaluate a patient with weakness and numbness in her legs. She was a 65-year-old woman with a 9 month history of progressive weakness and sensory loss and hadn’t been able to walk for over two months. She also had significant weight loss and during her examination was found to have a very large supraclavicular lymph node quite worrisome for a malignancy. We sent off all of her lab work which returned with an extremely high platelet count and an erythrocyte sedimentation rate of greater than 120, both also very worrisome indicators for malignancy. Neurologically, she had brisk reflexes in the legs and poor rectal tone, both suggestive of a spinal cord process. Top on our differential was a primary malignancy with a metastatic lesion to her lower spine and compression of her spinal cord. Unfortunately, none of this bode well for her prognosis and now it was time to make decisions about her care. If we obtained a CT scan, which would cost her family a significant amount, it would not likely change her management as the very best we could hope for would be sending her to Dar es Salaam to the only neurosurgeons in Tanzania to remove a tumor that would not improve her neurologically and then they would have to deal with the primary malignancy. We had no evidence that she had tuberculosis and given the large lymph node which was painless and hard making it more likely to be malignant rather than reactive from an infection. A discussion would have to be had with the patient and her family about her prognosis and whether they had the resources and/or the desire to know what was going on given the most likely scenario that she wouldn’t improve neurologically and would eventually succumb to this process. I will try to post the outcome of that conversation when it occurs. Regardless, it was a very good educational experience for both Laurita and Kelley not only as far as the evaluation of the patient was concerned, but also the discussion over treatment recommendations.

Evaluating our patient in the ward with likely metastatic disease to her cord

We finished a bit earlier which was good as we all had plans to go out for dinner with the entire neuro team and were heading to Carnivore for grilled chicken, chipsees (French fries), grilled plantains and beer. We had Dr. Badyano, Sokoine, Angel and Alex along with the three of us. The chicken here is the most tasty around we always look forward to this visit. Best of all, they play wonderful African dance music and have a small dance floor that we all monopolized until the wee hours after dinner (here that means 11pm). We all returned safely home after dropping off Angel and Badyano at their homes and went to bed for some sleep looking forward to our final clinical day here at FAME on the morrow. Each of us, though, knew that we would be missing FAME in very short order and would be leaving with heavy hearts.

Kelley during a lighter moment – no, she isn’t demonstrating right eye ptosis

Tuesday morning was once again time for our educational talks and there was a special request for Kelley and Laurita to cover the causes and evaluation of patients with altered mental status, a very broad topic that was quite a challenge for them to prepare. Like the pros they are, though, they tackled it with enthusiasm and came up with an excellent presentation that fully covered the topic. Once again, they had the full attention of the entire medical staff and when it was clear that they weren’t going to be able to finish the presentation in the time allotted (Dr. Lisso again did not cut them off which is always an excellent sign that they’re doing a good job) they were asked to finish the lecture on Thursday morning which is not a typical morning for educational lectures. Not only that, but the lecture that had gotten bumped for the altered mental status evaluation, headaches, was now being move to Friday morning, the morning we’re leaving for Arusha, but both Kelly and Laurita were more than willing to give the lecture before we leave that day. So, all in all, there will three educational lectures this week when there is normally only one.

Morning lecture

At morning rounds, we discovered that our young boy with meningoencephalitis was actually somewhat improved as he responded slightly. The night before, on our way home, Kelley had brought up the thought of covering him for listeria, which causes a brainstem encephalitis, as he did have some of these features on presentation. We stopped by the ward and wrote orders for ampicillin to cover him for Listeria. He continued to have fevers and had also had a few more seizures so we were keeping him on his anticonvulsant medication, but were considering adding another if he continued.

Patients in our neurology “waiting room”

Our young woman with Sydenham’s chorea was actually doing better after receiving the steroids, antibiotics and more diazepam to help her sleep the night. She was still having some confusion, though, and we knew it would take some time for everything to clear. Frank and I had a long discussion with her mother who was now also staying at FAME and tried to explain the nature of this disease to her. They are rural Maasai so it is very difficult to explain the nature of an infectious and Neuro-immunological disorder that isn’t contagious and wasn’t caused by anything her daughter or she did wrong, but just happens to some people when they develop a strep infection. She would be going home at some point and would probably still have some of her movements and confusion and we wanted to make certain that her family wouldn’t take her to a traditional healer or shaman where they might try to exorcise her. We frequently see patients here at FAME after they’ve been to a healer and they have lots of marks and burns on their bodies from attempted treatments or they’ve ingested local herbs that have unknown toxicities or effects. We also explained to her mother that this wouldn’t get better immediately, but would take at least several weeks to notice any possible benefits and that she would have to come back to be followed.

Laurita examing her patient with complaints of neuropathy and massive tophi

Laurita had a very interesting patient with the largest gouty tophi any of us had ever seen. Gabriel told us that this wasn’t as uncommon here as both of us thought as many patients are unfortunately non-compliant with their medications and many can have tophi such as this patient had. The reason he was seeing us, though, was because of his symptoms of neuropathy which were undoubtedly related to his gout. His examination confirmed his neuropathy and he was treatment with medication for symptomatic relief and hopefully he will be compliant with it.

Gouty tophi of the hand

A very large gouty tophus

No other patients stood out for the afternoon, but we were able to finish in a reasonable time today. I had driven downtown to pick up some things from one of the fabric stores after lunch, but they hadn’t given me everything for some reason, most likely because I was by myself and I’m not sure how clearly I had gotten the message across to them. So Kelley and I decided to run back down there before they closed for the evening and brought Selina along with us to help with any interpretation. It turned out that they had really failed to give me several things and it was unclear if they just weren’t sure if I was supposed to be picking up stuff for everyone or what. We had all ordered a number of things from them and given them quite a bit of business they wouldn’t have otherwise gotten so it seemed reasonable to us that they would want our business. We were never entirely sure, though, and that is something that is often the result of the cultural spread.

Kelley examining her patient

We returned home before sunset and once again sat on he veranda overlooking the beautiful hills that opened up in front of us. Dr. Liz, another volunteer from the US who has been here several times with me, arrived yesterday afternoon and joined us on the veranda to reminisce as well as to catch up on each other’s lives and the events of the day. We had the last of our prepared dinners as we’d be going out for the next two nights before we leave. What seemed like such a long time for us to be here now seems like it has slipped away so quickly and we are all becoming very sad at the thought of leaving soon.